standard operating procedures manual for assisters in the

Standard Operating Procedures Manual for Assisters in the Individual Federally-facilitated Marketplaces SOP 13 – UPDATE A MARKETPLACE ACCOUNT

MARKETPLACE ASSISTER TOOLKIT

Version 8.0 August 2021. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. The information provided in this document is intended only to be a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. This document summarizes current policy and operations as of the date it was presented. We encourage readers to refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. i

Table of Contents

SOP 13—UPDATE A MARKETPLACE ACCOUNT .....................................................................................1 A. Introduction .................................................................................................................... 1 B. Procedures ...................................................................................................................... 2

1. Update Account Profile ................................................................................... 2 2. Update Communication Preferences ............................................................. 3 3. Report Life Changes ........................................................................................ 4 4. Provide Proof of SEP Eligibility ........................................................................ 6 5. Change Health Coverage................................................................................. 8 6. Cancel or Terminate Coverage ..................................................................... 10

Appendix A: Frequently Asked Questions (FAQs) ................................................................... 12

This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. ii

List of Exhibits

Exhibit 1 – My Profile Screenshot ................................................................................................................. 2 Exhibit 2 – Communication Preferences Screenshot ................................................................................... 3 Exhibit 3 – Report a Life Change Screen ....................................................................................................... 5 Exhibit 4 – Life Changes ................................................................................................................................ 5 Exhibit 5 – Verifying SEP Eligibility Screenshot ............................................................................................. 8 Exhibit 6 – My Plans & Programs Screenshot ............................................................................................... 9 Exhibit 7 – Terminate Coverage Screenshot .............................................................................................. 10

This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. 1

SOP 13—Update a Marketplace Account

A. Introduction

Standard Operating Procedure (SOP) 13 provides guidance on assisting consumers as they update their eligibility application information. Consumers may experience life changes (e.g., marriage, relocation, birth of a child, or changes in household income, citizenship, or immigration status) during the year. The Federally-facilitated Marketplace (Marketplace or FFM) re-determines consumers’ eligibility after any changes are reported and notifies consumers of resulting changes in eligibility and next steps. In general, the Marketplace uses a consumer’s contact information and communication preferences they indicated in their HealthCare.gov account to send Marketplace communications such as notices. However, the consumer’s plan only receives information the consumer provides on the application either initially at enrollment or through a reported life change. Some changes, such as those made to communication preferences or a consumer’s account password, will have no effect on a consumer’s eligibility determination. Other updates to application information (which can be made using the “Report a Life Change” function), such as updating a state of residence or a change in income, may affect a consumer’s eligibility to obtain coverage through the Marketplace or for help paying for coverage.

It is important for consumers to report life changes to the Marketplace as soon as possible to determine whether:

• Their eligibility for Marketplace coverage or help paying for coverage has changed.

• They’re eligible for a Special Enrollment Period (SEP).

Consumers must report changes to their application information within 30 days of the change. The Marketplace re-determines consumers’ eligibility and notifies consumers of any changes in eligibility and next steps.

Consumers can only change their Marketplace plan outside of the annual Open Enrollment Period (OEP) if they have a life event that qualifies them for an SEP. If consumers qualify for an SEP, they generally have 60 days to select a plan. In some cases, new applicants who attest to certain SEP qualifying events must submit documents that confirm their SEP eligibility before the Marketplace finalizes their enrollment. Most consumers who qualify for an SEP and want to change plans may have a limited number of health plan “metal” categories to choose from (instead of all four) during their SEP. This means if consumers want to change plans during an SEP that they qualify for, they may need to select a new plan within the same plan category as their current plan or wait until the next OEP if they want to change to a plan in a different category. It may be possible for consumers to change to a plan in a different plan category during an SEP under certain circumstances. Assisters can find more information on circumstances that allow consumers to change plans at HealthCare.gov/coverage-outside-open-enrollment/changing-plans.

Consumers who wish to end coverage through an FFM can generally do so at any time. They don't need to wait for the OEP or qualify for an SEP. A consumer is generally considered to be terminating coverage if they’ve enrolled and paid at least one month’s premium (coverage is effectuated). Enrollee-initiated terminations are effective on the date the termination is requested or on another prospective date selected by the enrollee. A consumer is generally considered to be canceling coverage if they have not yet effectuated coverage with their first premium payment.

https://www.healthcare.gov/coverage-outside-open-enrollment/changing-plans/

https://www.healthcare.gov/coverage-outside-open-enrollment/changing-plans/



Marketplace coverage does not end automatically if a consumer is found eligible for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). Consumers who are found eligible for other coverage should terminate their Marketplace coverage, unless they want to stay in their plan without financial assistance. If these consumers do not cancel their enrollment with financial assistance through the Marketplace, they may have to pay back some or all of the advance payments of the premium tax credit (APTC) that they received through the Marketplace for the months they were eligible for Medicare coverage.

B. Procedures

1. Update Account Profile

Consumers updating their account profiles should complete the following steps:

Step 1. Consumers can log into their accounts at HealthCare.gov and select the “My Profile” tab as shown in Exhibit 1.

Exhibit 1 – My Profile Screenshot

Step 2. Consumers can change the following information on the “My Profile” tab:

• Password

• Email address

https://www.healthcare.gov/



• Phone number

• Address*

• Security questions

*To update addresses to a new ZIP code, county, or state, consumers must report a life change. This address change may affect consumers’ eligibility or the plans available to them.

2. Update Communication Preferences

Consumers updating their communication preferences should complete the following steps:

Step 1. Consumers can log into their accounts at HealthCare.gov and select the “My Applications & Coverage” tab. Consumers then select the application to update.

Step 2. Consumers should select the “Communication Preferences” tab as shown in Exhibit 2.

Exhibit 2 – Communication Preferences Screenshot

Step 3. Consumers can change the following information on the “Communication Preferences” tab:




• Email address

• Phone number

• Second phone number

• Notifications (i.e., prefer to receive via text message or email)

• Notices (i.e., prefer to receive electronic or paper notices*)

• Preferred spoken language

• Preferred written language

*Consumers may also edit the address to which they would like paper notices sent. To update addresses to a new ZIP code, county, or state, consumers must report a life change. Changes to consumers’ home addresses may affect their eligibility or the plans available to them.

3. Report Life Changes

Consumers updating a Marketplace application to report a life change should complete the following steps:

Step 1. Consumers should log into their Marketplace account at HealthCare.gov and select the “My Applications & Coverage” tab, then select the application to update to reflect life changes.

Step 2. Consumers should select the “Report a Life Change” tab displayed in Exhibit 3.




Exhibit 3 – Report a Life Change Screen

Step 3. Examples of life changes that consumers should report are listed below in Exhibit 4.

Exhibit 4 – Life Changes

Life Event Potential Updates Citizenship/Immigration Status Change

• Change in citizenship or immigration status for a household member needingcoverage

Residency Changes • Report a new residential addressIncarceration Status Change • Change in incarceration status for a household member

Tax Filing Status Change • Change in tax filing status (e.g., married, single, divorced)• Add, remove, or change tax dependents

Pregnancy Status Change • Change in pregnancy status



Life Event Potential Updates

Household Member Change

• Add or remove household member (including through birth, adoption, or placementof child for adoption)

• Change household members’ names• Correction to date of birth or Social Security Number• Update marital status or other family relationships• Report a household member’s physical disability or mental health condition that

limits their ability to work, attend school, or take care of daily needs• Remove household member from coverage• Change in status as an American Indian/Alaska Native or tribal member

Change in Request to Health Plan Costs

• Request advance payments of the premium tax credit (APTC) and cost-sharingreductions (CSRs)

• End request for APTC and CSRsIncome Change • Increase or decrease in incomeEmployer-Sponsored Minimum Essential Coverage (MEC) Change

• Changes to job-based coverage (e.g., changes premiums, coverage no longer offeredby employer)

• Household member gets a new offer of job-based coverage

Other MEC Changes

• Gained or lost health coverage (e.g., coverage that you had through a familymember, Medicaid, CHIP, Medicare) in the last 60 days

• Will gain or lose health coverage in the next 60 days• Gained (or will gain) eligibility for Medicare coverage on 65th birthday or receives

disability benefits

Step 4. Consumers select the type of change they would like to report.

Step 5. Assisters should remind consumers that their eligibility results may change as a result of the life change and explain how this may affect their coverage options.

Step 6. Consumers should submit any required supporting documents and review their updated eligibility results.

4. Provide Proof of SEP Eligibility

The Special Enrollment Confirmation Process, or SEP verification, requires new applicants seeking coverage outside of the OEP to provide proof to the Marketplace of their eligibility for certain types of SEPs. This is required after the applicant has attested to eligibility for an applicable SEP and selected a qualified health plan (QHP). Consumers should submit required documents to the Marketplace by the deadline provided in their eligibility determination notice (EDN). Consumers generally have 30 days to submit documents once they select a plan.

CMS will mail a resolution notice to consumers if the documents they submitted are sufficient to prove their eligibility for an SEP. Consumers who submit insufficient documents will receive a notice asking for additional documents. If consumers do not respond or do not provide sufficient documents, they can be found ineligible for their SEP and lose their chance to enroll until the next OEP (unless they experience another life event that makes them eligible for another SEP).

Things You Should Know • The system may return a list of the

supporting documents requireddepending on the life changesreported. Consumers will see boththeir previously uploadeddocuments and those that theystill need to upload.



Consumers enrolling through five common SEPs must submit documents to verify their eligibility to use an SEP before they can enroll and start using their coverage. These SEPs are:

• Loss of MEC;

• Change in primary place of living, if the consumer was enrolled in coverage while living at the original place of residence;1

• Denial of coverage through Medicaid or CHIP;

• Gaining or becoming a dependent through adoption, placement for adoption, placement in foster care, or a child support or other court order; and

• Marriage.

Consumers who applied for Marketplace coverage will be asked to provide documents to verify their eligibility for an SEP as displayed in Exhibit 5.

1 Consumers must show they had qualifying health coverage for one or more days in the 60 days before their move, unless they’re moving from a foreign country or United States territory. Note, however, that moving only for medical treatment or staying somewhere temporarily without intending to reside there (for example, a vacation) doesn’t qualify a consumer for an SEP.



Exhibit 5 – Verifying SEP Eligibility Screenshot

5. Change Health Coverage

Consumers who wish to change their Marketplace plan should complete the following steps:

Step 1. Consumers should log into their Marketplace account at HealthCare.gov and select the “My Applications & Coverage” tab, then select their current application.

Step 2. Consumers should select the “My plans & programs” tab displayed in Exhibit 6.




Exhibit 6 – My Plans & Programs Screenshot

Step 3. Consumers should select the Change Plans button to continue to enrollment and select a new health and dental plan, if applicable.



6. Cancel or Terminate Coverage

In general, consumers can end coverage for all or some household members at any time. A consumer is generally considered to be terminating their plan if they have paid at least one month’s premium (i.e., their coverage is effectuated), and a consumer is generally considered to be canceling their plan if they have not yet effectuated their coverage with their first premium payment.

6.1 Ending Marketplace Coverage for the Household Contact Only

The household contact is usually the person who created the Marketplace account and may have filled out the application to buy the Marketplace plan for his or her spouse or dependents.

To cancel Marketplace coverage for the household contact or change the household contact, consumers must contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). Consumers should not try to change or remove the household contact online unless they are ending coverage for everyone on the plan. It is important to change or remove the household contact by phone to confirm dependents remain on the plan, if possible. Assisters can find more information on ending coverage for household members at Consumer Options for Terminating Plans and Reporting Changes.

6.2 Ending Marketplace Coverage for Everyone on the Plan

Consumers who are terminating coverage for all household members in an FFM should complete the following steps:

Step 1. Consumers should log into their Marketplace account at HealthCare.gov and select the “My Applications & Coverage” tab, then select their current application.

Step 2. Consumers should select the “My plans & programs” tab and navigate to the bottom of the page to terminate coverage as displayed in Exhibit 7.

Exhibit 7 – Terminate Coverage Screenshot

Step 3. Consumers should select End (Terminate) All Coverage to end their coverage. Assisters should remind consumers that terminating all coverage will end consumers' health and dental plans. If consumers bought a stand-alone dental plan (SADP) when they enrolled in a Marketplace health plan, they can end only their dental coverage by selecting End (Terminate) Dental Coverage.

Step 4. Consumers should select their household’s desired coverage end date.

https://marketplace.cms.gov/technical-assistance-resources/terminating-plans-and-reporting-changes.pdf

https://marketplace.cms.gov/technical-assistance-resources/terminating-plans-and-reporting-changes.pdf




Step 5. Consumers should check the attestation box then select the red Terminate Coverage button. On the “My plans & programs” tab, a red “Terminated” or “Cancelled” status should appear above the plan the consumer ended.

6.3 Ending Marketplace Coverage for Some Household Members on the Plan

Consumers can generally end coverage for only some household members on their Marketplace plan (i.e., a spouse or dependents). If consumers are ending coverage for just some household members on the application, in most cases, coverage for these individuals will end immediately. The best way to ensure consumers receive their desired coverage end date is by requesting the change by contacting the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889- 4325).



Appendix A: Frequently Asked Questions (FAQs)

The FAQs below are designed to help assisters answer consumers’ specific questions on updating their online accounts through the Individual Marketplace.

FAQ 1. What account changes/updates will affect my eligibility to participate in the Marketplace or to get help paying for coverage?

Answer: Certain life changes, like gaining citizenship, marriage, or the birth of a child, may affect eligibility. However, account maintenance updates, like changing your password or email, will not affect your eligibility.

FAQ 2. How do I change my account details (e.g., password, email)?

Answer: You may log into your account, select the “My Profile” tab, and follow the system instructions to complete any account changes.

FAQ 3. If I’ve already mailed in my paper eligibility application, can I update my information later online?

Answer: If you have submitted a paper application to the Marketplace, you can make changes to your application information online. You will need to create an account online, answer questions to prove your identity, and then use the “Find Application” function to associate the application with the account. You will need your application ID number to retrieve your application. If you’re not sure of your application ID number, you can contact the Marketplace Call Center.

FAQ 4. When should I report a life change?

Answer: Consumers must report changes to their eligibility information within 30 days of the change. However, consumers should report changes in circumstances as soon as possible to make sure they are receiving the correct amount of financial assistance and avoid owing money related to APTC when they file their federal income tax returns.

standard operating procedures manual for assisters in the

Documents